Surgical Quality Improvement Program Dataset Research Articles

Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program.

To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN. The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach. The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008). Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

Incidence, Risk Factors, and Subsequent Complications of Postoperative Hematomas Requiring Reoperation After Primary Total Hip Arthroplasty

BackgroundStudies analyzing the incidence and clinical implications of postoperative hematomas after total hip arthroplasty (THA) remain limited. The purpose of the present study was to use the National Surgical Quality Improvement Program (NSQIP) dataset to determine rates, risk factors, and subsequent complications of postoperative hematomas requiring reoperation after primary THA. MethodsStudy population included patients who underwent primary THA (CPT code: 27130) from 2012-2016 recorded in NSQIP. Patients who developed a hematoma requiring reoperation in the 30-day postoperative period were identified. Multivariate regressions were created to identify patient characteristics, operative variables, and subsequent complications that were associated with a postoperative hematoma requiring reoperation. ResultsAmong the 149,026 patients who underwent primary THA, 180 (0.12%) developed a postoperative hematoma requiring reoperation. Risk factors included body mass index (BMI) ≥ 35 (relative risk [RR]: 1.83, P = .011), American Society of Anesthesiologists (ASA) class ≥3 (RR: 2.11, P < .001), and history of bleeding disorder (RR: 2.71, P < .001). Associated intraoperative characteristics were an operative time ≥100 minutes (RR: 2.03, P < .001) and use of general anesthesia (RR: 1.41, P = .028). Patients developing a hematoma requiring reoperation were at higher risk of subsequent deep wound infection (RR: 21.57, P < .001), sepsis (RR: 4.3, P = .012), and pneumonia (RR: 3.69, P = .023). ConclusionsSurgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA. Several nonmodifiable and modifiable risk factors were identified. Given the 21.6 times increased risk of subsequent deep wound infection, select, at-risk patients may benefit from closer monitoring for signs of infection.

Development of a Risk Score to Predict Post-Discharge Rehabilitation Care After Liver Metastasectomy

IntroductionNeed for discharge to intermediate care (DCIC) can increase length of stay and be a source of stress to patients. Estimating risk of DCIC would allow earlier involvement of case managers, improve length of stay and patient satisfaction by setting realistic expectations. The aim was to use National Surgical Quality Improvement Program dataset to develop a prediction model for DCIC after undergoing liver metastasectomy. MethodsData were obtained from National Surgical Quality Improvement Program 2011-2018 covering liver metastasectomy. Recursive partitioning narrowed potential predictors and identified thresholds for categorization of continuous variables. Logistic regression identified a predictive model, internally validated by using 200 bootstrap samples with replacement. A risk score was derived using Framingham Study methodology by dividing all regression coefficients by the smallest model coefficient. Receiver operating characteristic analysis identified the score that maximized sensitivity/specificity, defining low/high risk. Finally, recursive partitioning identified categories low/medium/high. ResultsThe most parsimonious model predicting DCIC area under the curve (, 0.722, 95%CI: 0.705-0.739) identified five independent predictors including age >60, procedure type, hypertension requiring medication, albumin <3.5 mg/dL and hematocrit <30%. Internal validation resulted in expected bias-corrected area under the curve of 0.717, 95% CI: 0.698-0.732. The maximum score was 17.9 and 5.8 maximized sensitivity (sn) and specificity (sp) [sn = 81%, sp = 51%) predicting DCIC. Stratified into three groups, a score ≥9.5 identified highest risk (12.8%), ≥4.3 medium (6.1%) and <4.3 lowest risk (1.5%). ConclusionsDetermining risk of DCIC benefits shared decision making and patient care. This evidence may enhance discharge planning after liver metastasectomy expediting the process. Age >60 contributed the most weight to the score, but the use of additional variables in three groups allowed further discrimination between patients.

National Assessment of Early Discharge After Video-Assisted Thoracoscopic Surgery for Lung Resection.

Video-assisted thoracoscopic surgery (VATS) techniques permit shorter postoperative length of stay (LOS). However, it remains unknown whether earlier discharge increases the risk of adverse postoperative events. We examined whether shorter LOS following elective VATS lung resection was associated with increased rates of readmission or postoperative complications. Patients who underwent elective thoracoscopic segmentectomy, lobectomy, or bilobectomy for lung neoplasms from 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Postoperative LOS was treated as an ordinal variable. The examined outcomes were 30-d readmission and 30-d postdischarge death or serious morbidity (DSM). Multivariable logistic regression models evaluated the association of LOS with outcomes. The most common readmission diagnoses were identified for each operation. Among 14,418 patients, 12,410 (86.1%) underwent lobectomy, 1764 (12.2%) underwent segmentectomy, and 244 (1.7%) underwent bilobectomy. The median LOS was 3d for patients undergoing lobectomy (IQR 2-5) and segmentectomy (IQR 2-4), and 4d for bilobectomy (IQR 3-6). Readmission rates varied with admission time and ranged from 5.0% for patients with LOS ≤1d to 8.5% for LOS ≥5d. The most common readmission diagnoses were pneumothorax (19.0%) and wound complications (13.4%). Each one-day increase in LOS was associated with an increased risk of readmission (OR 1.10, 95% CI 1.04-1.17, P<0.001). No association was seen between earlier discharge and DSM (OR 1.08, 95% CI 0.99-1.18, P=0.070). Early discharge following VATS lung resection is not associated with increased rates of readmission or postoperative complications among patients undergoing surgery for cancer, and may safely be considered for selected patients with uncomplicated postoperative recovery.

The Association Between Metabolic Derangement and Wound Complications in Elective Plastic Surgery

IntroductionThe incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk. MethodsPatients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI] > 30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI > 30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status. ResultsOf 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P < 0.001) and adverse events (12.4% versus 9.6%; P < 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P < 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P < 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P < 0.001). ConclusionsDiabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.

Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: analysis of the National Surgical Quality Improvement Program dataset: Presented in abstract form at the American College of Surgeons Quality and Safety Conference, Washington, DC, July 19-22, 2019; and accepted for presentation at the Forty-eighth Annual Symposium of the Society for Clinical Vascular Surgery, Huntington Beach, Calif, March 14-20, 2020

Background The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR).

Historical and Forecasted Changes in Utilization of Same-day Discharge after Minimally Invasive Hysterectomy

To describe changes in length of stay and same-day discharges (SDDs) after minimally invasive hysterectomy (MIH) over the last decade and forecast anticipated utilization over the subsequent decade. Cross-sectional analysis. American College of Surgeons National Surgical Quality Improvement Program database. All benign MIH excluding joint cases with concomitant nongynecologic surgery in the 2011 to 2019 National Surgical Quality Improvement Program datasets, identified by Current Procedural Terminology code. A descriptive analysis of changes in the estimated length of stay and utilization of SDD from 2011 to 2019. Multivariable negative binomial regression assessed for individual-level risk factors for prolonged hospital stay and autoregressive linear forecasting estimated the growth of SDD through 2029. A total of 239 220 MIH were identified. Over the 9-year period, SDD increased by 10.7% across all MIH. However, in 2019, SDD represented only 29.8% of total MIH discharges and utilization varied by surgical approach (laparoscopic hysterectomy, 35.4%; vaginal hysterectomy, 18.6%; laparoscopic-assisted vaginal hysterectomy, 19.6%) and a surgical indication of pelvic organ prolapse (32.7% without and 13.9% with prolapse). Multivariable models controlling for patient characteristics showed independent associations of route and indication for MIH and length of stay (adjusted relative rate, 1.30; 95% confidence interval [CI], 1.29-1.32 for vaginal hysterectomy, and adjusted relative rate, 1.12; 95% CI, 1.11-1.14 for prolapse); however, these individual-level factors provided limited information explaining variation in the length of stay (model pseudo-R2, 0.054). Forecasting models suggest that utilization of SDD will grow to 48.5% (95% CI, 38.7-58.4) by the end of 2029. Although the estimated length of stay is decreasing among MIH over time, the utilization of SDD remained low in 2019 and was not explained by patient factors. If current trends hold, SDD utilization is not forecast to exceed 50% through 2029. Additional efforts focused on the provider and institution level are needed to encourage SDD as the standard of care for MIH.

Morbidity and mortality following noncardiac surgical procedures among children with autosomal trisomy.

Trisomy 13 (T13), trisomy 18 (T18), and trisomy 21 (T21) are the most common autosomal trisomies. One unifying feature of all trisomies is their association with major congenital malformations, which often require life-prolonging surgical procedures. Few studies, mostly among cardiac surgery patients, have examined the outcome of those who undergo surgical procedures. We examined the differences in postsurgical outcomes between the trisomy groups. Using the National Surgical Quality Improvement Program dataset, we identified children (<18years of age) with T13, T18, or T21 who underwent noncardiac surgery (2012-2018). We estimated the incidence of mortality and indicator of resource utilization (unplanned reoperation, unplanned tracheal reintubation, and extended length of hospital stay). Of the 349 158 inpatient surgical cases during the study period, we identified 4202 children with one of the autosomal trisomies of interest (T13: 152; T18: 335; and T21: 3715). The rates of postoperative mortality were substantially higher for T18 and T13 than T21 and nontrisomy children (T18 vs. T21: 11.1% vs. 1.6%, adjusted odds ratio: 5.01, 95%CI: 2.89,8.70, p<.01), (T13 vs. T21: 8.1% vs. 1.6%, adjusted odds ratio: 2.86, 95%CI: 1.25,6.54, p=.01). Children with T18 had the highest rates of extended length of stay (62.7%) and prolonged mechanical ventilation (32.5%). T18 and T13 neonates had the highest surgical mortality burden (T13: 26.5%, T18: 31.8%, and T21: 2.8%). Approximately, one-third of T18 and T13 neonates, who had surgery, died, underscoring the lethality of these trisomies and the need for a comprehensive preoperative ethical discussion with families of these children.

Diabetes Adversely Influences Postoperative Outcomes After Oesophagectomy: An Analysis of the National Surgical Quality Improvement Program Database.

Introduction: Diabetes is a recognised risk for several chronic and acute illnesses, including increased complications in surgery for oesophageal cancer. Our primary aim is to determine the impact of diabetes on postoperative surgical and medical complications after oesophagectomy.Methods: All oesophagectomies for malignancy as reflected in the 2016-2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) datasets were extracted and analysed. Current Procedural Terminology (CPT) codes used were 1) open procedures (43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, and 43123) and 2) hybrid procedures (43186, 43287, and 43288).Logistic regression models examined associations between diabetic status and adverse outcomes. The associations were adjusted for sex, race, age group, operation year, CPT code, body mass index (BMI), smoking, congestive heart failure, antihypertensives, renal failure, and dyspnoea.Results: Two thousand five hundred and thirty-eight oesophagectomies were identified. 86.45% (n=2,194) underwent open procedures and 13.55% (n=344) had hybrid procedures. There were 177 insulin-dependent diabetics (IDDM) and 320 (12.61%) non-insulin-dependent diabetics (NIDDM). 84.14% were male and 77.74% were Caucasian. 89.48% of the patients were between 50 and 79 years of age. 40.27% experienced postoperative complications. Medical complications (odds ratio [OR]: 1.7, p-value: 0.002), surgical complications (OR: 1.9, p-value: <0.001), wound complications (OR: 2.9, p-value: <0.001), and anastomotic leaks (OR: 2.4, p-value: <0.001) were more common in diabetic patients. Subgroup analysis showed that in hybrid procedures, there is a statistically significant increase in the OR of surgical complications (OR: 3.61, p-value: 0.05), medical complications (OR: 3.76, p-value: 0.04), and anastomotic leak (OR: 3.49, p-value: 0.27) in IDDM as compared to NIDDM.Conclusion: Insulin-dependent diabetes doubles the risk of all major complications compared to nondiabetics. When considering surgical approach and diabetic status (IDDM vs nondiabetics, NIDDM vs nondiabetics), the risk of complications further doubles for hybrid oesophagectomies compared to open procedures.

Complications Associated with Anesthetic Choice for Elective Foot and Ankle Surgery

Category:Ankle; Ankle Arthritis; Arthroscopy; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Wide-awake anesthesia (local anesthesia without sedation) is rarely utilized during elective foot and ankle surgery. As such, the rate of post-operative complications following wide-awake foot and ankle surgery is unknown. The aim of this study was to compare rates of early post-operative complications for wide-awake anesthesia to general/local anesthesia with sedation for elective foot and ankle procedures conditional on a wide range of observable patient characteristics and risk factors.Methods:Patients that underwent an elective foot or ankle surgery were identified in the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) dataset. The rate of thirty-day post-operative complications was compared between patients who received wide-awake anesthesia and those who received general/local anesthesia with sedation using logistic regressions that controlled for patient risk factors.Results:Between 2005 and 2017, 85,363 patients were identified has having any foot and ankle procedure. After excluding observations with missing anesthesia type data information and non-elective foot and ankle procedures, the analytic cohort had 16,743 patients. There were 1,401 (8.4%) patients who underwent wide-awake anesthesia and 15,342 (91.6%) patients who underwent general/local anesthesia with sedation over the entire sample. Starting in 2007, there was an annual increase in the likelihood of using general/local anesthesia with sedation for foot and ankle procedures of 0.7 percentage points (p = 0.001). Overall, general/local anesthesia with sedation increased the odds of experiencing any complication within the first thirty days by 1.523 (95% CI 1.152 - 2.014).Conclusion:Although wide-awake surgery is rarely performed for elective foot and ankle procedures, utilization of local anesthesia without sedation may result in fewer post-operative complications in the first thirty days. Existing trends in the use of sedation for foot and ankle procedures show that physicians are increasingly favoring general/local anesthesia with sedation, but our findings caution against this choice and suggest that post-operative complication rates may correspondingly increase.

The effect of operative duration on the outcome of colon cancer procedures.

Prolonged operative duration has been associated with increased post-operative morbidity in numerous surgical subspecialties; however, data are limited in operations for colon cancer specifically and existing literature makes unwarranted methodological assumptions of linearity. We sought to assess the effects of extended operative duration on perioperative outcomes in those undergoing segmental colectomy for cancer using a methodologically sound approach. We conducted a retrospective cohort study of patients undergoing segmental colectomy for cancer between 2014 and 2018, logged in the National Surgical Quality Improvement Program datasets. Our primary outcome was a composite of any complication within 30days; secondary outcomes included length of stay and discharge disposition. Our main factor of interest was operative duration. We analyzed 26,380 segmental colectomy cases, the majority of which were approached laparoscopically (64.95%) and were right sided (62.93%). Median operative duration was 152 (95% CI 112-206) minutes. On multivariable regression, increased operative duration was linearly associated with any complication (OR = 1.003, 95% CI 1.003-1.003, p < 0.0001) in the overall cohort, as was length of stay (p < 0.0001). All subgroups except for the laparoscopic left colectomy group were linearly associated with operative duration. In the laparoscopic left colectomy group, an inflection point in the odds of any complication was found at 176min (OR = 1.39, 95% CI 1.20-1.61, p < 0.0001). This study suggests that the risk of perioperative complications increases linearly with increasing operative duration, where each additional 30min increases the odds of complication by 10%. In those undergoing laparoscopic left colectomy, the risk of complications sharply increases after ~3h, suggesting that surgeons should aim to complete these procedures within 3h where possible.

Pre-Operative Risk Factors for Anastomotic Leak after Bowel Resection for Endometriosis

Study Objective Determine the preoperative risk factors for anastomotic leak after bowel resection during non-emergent endometriosis related surgery. Design Retrospective population level case-control study. Setting Analysis of American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset. Patients or Participants Patients undergoing a bowel resection for endometriosis related surgery from 2014-2019 at a NSQIP participating site. International Classification of Diseases codes (ICD 9/10) were utilized to identify bowel resection cases with a primary surgical indication for endometriosis. Interventions Evaluation of patient demographics, perioperative management strategies and surgical technique that were associated with the occurrence of an anastomotic leak following bowel resection for endometriosis. Measurements and Main Results 289 bowel resection cases (non-emergent, benign) for endometriosis were identified. Anastomotic leak occurred in 9 cases (3.11%). There were no baseline patient demographics, perioperative management strategies (mechanical bowel preparation, preoperative oral antibiotics) or differences in surgical technique (laparoscopic vs open) that demonstrated a statistically significant association with an anastomotic leak. Multivariable logistic analysis identified that an increased preoperative albumin level was associated with a reduced risk of anastomotic leak with an adjusted odds ratio of 0.11 (95% CI 0.01-0.95). Conclusion The majority of population level data for anastomotic leak after bowel resection has included mainly data involving surgery for cancer. Data on complications after bowel resection for endometriosis has primarily been published form single site, single surgeon case series. This study using multicenter national data identified decreased preoperative albumin level as a risk factor for anastomotic leak after bowel resection for endometriosis. Further prospective studies are warranted to identify possible optimization strategies before bowel resection for endometriosis, with a particular focus on nutritional status atop perioperative management strategies and surgical techniques. Determine the preoperative risk factors for anastomotic leak after bowel resection during non-emergent endometriosis related surgery. Retrospective population level case-control study. Analysis of American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset. Patients undergoing a bowel resection for endometriosis related surgery from 2014-2019 at a NSQIP participating site. International Classification of Diseases codes (ICD 9/10) were utilized to identify bowel resection cases with a primary surgical indication for endometriosis. Evaluation of patient demographics, perioperative management strategies and surgical technique that were associated with the occurrence of an anastomotic leak following bowel resection for endometriosis. 289 bowel resection cases (non-emergent, benign) for endometriosis were identified. Anastomotic leak occurred in 9 cases (3.11%). There were no baseline patient demographics, perioperative management strategies (mechanical bowel preparation, preoperative oral antibiotics) or differences in surgical technique (laparoscopic vs open) that demonstrated a statistically significant association with an anastomotic leak. Multivariable logistic analysis identified that an increased preoperative albumin level was associated with a reduced risk of anastomotic leak with an adjusted odds ratio of 0.11 (95% CI 0.01-0.95). The majority of population level data for anastomotic leak after bowel resection has included mainly data involving surgery for cancer. Data on complications after bowel resection for endometriosis has primarily been published form single site, single surgeon case series. This study using multicenter national data identified decreased preoperative albumin level as a risk factor for anastomotic leak after bowel resection for endometriosis. Further prospective studies are warranted to identify possible optimization strategies before bowel resection for endometriosis, with a particular focus on nutritional status atop perioperative management strategies and surgical techniques.

Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: Analysis of the National Surgical Quality Improvement Program dataset

BackgroundThe present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR). MethodsPatients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days. ResultsA total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001). ConclusionsNonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.

Analysis of Risk Factors, Complications, Reoperations, and Demographics Associated With Open and Arthroscopic Rotator Cuff Repair: An Analysis of a Large National Database

To assess the national trends in arthroscopic and open rotator cuff repair surgery and the associated demographics, complications, and risk factors specific to each procedure. A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) dataset between the years 2007 and 2018. Patients were identified using Common Procedural Terminology codes for open and arthroscopic rotator cuff repair. Variables collected including basic demographics, procedural, and outcome specific variables as available through the NSQIP repository. Appropriate statistical measures were used to compare the groups, with the χ2 test used for categorical variables and t test for continuous variables. The arthroscopic cohort comprised 39,013 patients; the open group consisted of 8,664. Reported arthroscopic and open cases increased significantly between 2007 and 2018 from 135 to 7,269 and 65 to 1,168, respectively. Average operative time for arthroscopic procedure was 89 minutes and 76 minutes for open. The open group consisted of a slightly greater percentage of smokers, 18.3% versus 15.2%, and patients with diabetes, 18.2% versus 15.9%, both of which were statistically significant (P < .001). Open cases had an odds ratio of 3.05 for superficial infections and 7.40 for deep infections, both of which were statistically significant (P < .001). The open cohort also had an odds ratio of 1.71 for unplanned readmissions when compared with the arthroscopic cohort, which was also statistically significant (P < .001). According to the NSQIP database, the increase in arthroscopic procedures is significantly outpacing the increase in open procedures during this study period, which matches the trends seen in previous studies. Patients with diabetes and who smoke also represent a greater risk group for postoperative complications when undergoing open surgery. These findings suggest that perhaps the decision to pursue one technique over the other may be influenced both by provider preference and patient-related factors. III, retrospective comparative trial.

Machine learning approaches in predicting ambulatory same day discharge patients after total hip arthroplasty

BackgroundWith continuing financial and regulatory pressures, practice of ambulatory total hip arthroplasty is increasing. However, studies focusing on selection of optimal candidates are burdened by limitations related to traditional statistical...

Not all risk scores are created equal: A comparison of risk scores for abdominal aortic aneurysm repair in administrative data and quality improvement registries

ObjectiveAccurate and contemporary prognostic risk prediction is essential to inform clinical decision-making surrounding abdominal aortic aneurysm (AAA) care. Therefore, we validated and compared three different in-hospital mortality risk scores in one administrative and two quality improvement registries. MethodsWe included patients who had undergone elective AAA repair from 2012 to 2015 in the National Inpatient Sample (NIS), Vascular Quality Initiative (VQI; excluding the New England region), and the National Surgical Quality Improvement Program (NSQIP) datasets to validate three risk scores: Medicare, the Vascular Study Group of New England (VSGNE), and Glasgow Aneurysm Score (GAS). The receiver operating characteristic area under the curve (AUC) of all risk scores was calculated, and their discrimination was compared within a dataset using the Delong test and between datasets using a Z test. We constructed graphic calibration curves for the Medicare and VSGNE risk scores and compared the calibration using an integrated calibration index, which indicates the weighted average of the absolute difference between the calibration curve and the diagonal line of perfect calibration. ResultsWe identified a total of 25,461 NIS, 18,588 VQI, and 8051 NSQIP patients who had undergone elective open or endovascular AAA repair. Overall, the Medicare risk score was more likely to overestimate mortality in the quality improvement registries and the VSGNE risk score underestimated mortality in all the databases. After endovascular AAA repair, the Medicare risk score had a higher AUC in the NIS than in the GAS (P < .001) but not compared with the VSGNE risk score (P = .54). The VSGNE risk score was associated with a significantly higher receiver operating characteristic AUC compared with the Medicare (P < .001) and GAS (P < .001) risk scores in the VQI registry. Also, the VSGNE risk score showed improved calibration compared with the Medicare risk score across all three databases (P < .001 for all). After open repair, the Medicare risk score showed improved calibration compared with the VSGNE risk score in the NIS (P < .001). However, in the VQI registry, the VSGNE risk score compared with the Medicare risk score had significantly better discrimination (P = .008) and calibration (P < .001). ConclusionsOverall, the VSGNE risk score performed best in the quality improvement registries but underestimated mortality. However, the Medicare risk score demonstrated better calibration in the administrative dataset after open repair. Although the VSGNE risk score appeared to perform better in the quality improvement registries, its overly optimistic mortality estimates and its reliance on detailed anatomic and clinical variables reduces its broader applicability to other databases.

Racial Disparities in Perioperative Morbidity Following Oncological Spine Surgery.

Retrospective cohort study. To assess the impact of race on complications following spinal tumor surgery. Adults with cancer who underwent spine tumor surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program datasets from 2012 to 2016. Clavien-Dindo Grade I-II (minor complications) and Clavien-Dindo Grade III-V (major complications including 30-day mortality) complications were compared between non-Hispanic Whites (NHW) and Black patients. A multivariable analysis was also conducted. Of 1,226 identified patients, 85.9% were NHW (n = 1,053) and 14.1% were Black (n = 173). The overall rate of Grade I-II complications was 16.2%; 15.1% for NHW patients and 23.1% for Black patients (P = .008). On multivariable analysis, Black patients had significantly higher odds of having a minor complication (OR 1.87; 95% CI, 1.16-3.01; P = .010). On the other hand, the overall rate of Grade III-V complications was 13.3%; 12.5% for NHW patients and 16.2% for Black patients (P = .187). On multivariable analysis, Black race was not independently associated with major complications (OR 1.26; 95% CI, 0.71-2.23; P = .430). Median length of stay was 8 days (IQR 5-13) for NHW patients and 10 days (IQR 6-15) for Black patients (P = .011). Black patients who underwent metastatic spinal tumor surgery were at a significantly increased risk of perioperative morbidity compared to NHW patients independent of baseline and operative characteristics. Major complications did not differ between groups. Race should be further studied in the context of metastatic spine disease to improve our understanding of these disparities.

Racial Disparities in Surgery: A Cross-Specialty Matched Comparison Between Black and White Patients.

To determine if Black race is associated with worse short-term postoperative morbidity and mortality when compared to White race in a contemporary, cross-specialty-matched cohort. Growing evidence suggests poorer outcomes for Black patients undergoing surgery. A retrospective analysis was conducted comprising of all patients undergoing surgery in the National Surgical Quality Improvement Program dataset between 2012 and 2018. One-to-one coarsened exact matching was conducted between Black and White patients. Primary outcome was rate of 30-day morbidity and mortality. After 1:1 matching, 615,118 patients were identified. Black race was associated with increased rate of all-cause morbidity (odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.08-1.13, P < 0.001) and mortality (OR = 1.15, 95% CI 1.01-1.31, P = 0.039). Black race was associated with increased risk of re-intubation (OR = 1.33, 95% CI 1.21-1.48, P < 0.001), pulmonary embolism (OR = 1.55, 95% CI 1.40-1.71, P < 0.001), failure to wean from ventilator for >48 hours (OR = 1.14, 95% CI 1.02-1.29, P < 0.001), progressive renal insufficiency (OR = 1.63, 95% CI 1.43-1.86, P < 0.001), acute renal failure (OR = 1.39, 95% CI 1.16-1.66, P < 0.001), cardiac arrest (OR = 1.47, 95% CI 1.24-1.76 P < 0.001), bleeding requiring transfusion (OR = 1.39, 95% CI 1.34-1.43, P < 0.001), DVT/thrombophlebitis (OR = 1.24, 95% CI 1.14-1.35, P < 0.001), and sepsis/septic shock (OR = 1.09, 95% CI 1.03-1.15, P < 0.001). Black patients were also more likely to have a readmission (OR = 1.12, 95% CI 1.10-1.16, P < 0.001), discharge to a rehabilitation center (OR = 1.73, 95% CI 1.66-1.80, P < 0.001) or facility other than home (OR = 1.20, 95% CI 1.16-1.23, P < 0.001). This contemporary matched analysis demonstrates an association with increased morbidity, mortality, and readmissions for Black patients across surgical procedures and specialties.

Thirty-day outcomes after gynecologic oncology surgery: A single-center experience of enhanced recovery after surgery pathways.

The purpose of the study is to evaluate the impact of an enhanced recovery after surgery (ERAS) program implemented in a Gynecologic Oncology population undergoing a laparotomy at a Canadian tertiary care center. Prospectively collected data, using the American College of Surgeons' National Surgical Quality Improvement Program dataset (ACS NSQIP), was used to compare 30-day postoperative outcomes of gynecologic oncology patients undergoing a laparotomy before and after the 2018 implementation of an ERAS program in a Canadian regional cancer center. Patient demographics, surgical variables and postoperative outcomes of 187 patients undergoing surgery in 2019 were compared with those of 441 patients undergoing surgery between January 2016 and December 2017. Student's t, Mann-Whitney U and Chi-square tests, as well as multivariate linear and logistic regressions were used to evaluate baseline characteristics and 30-day postoperative complications. Length of stay was significantly shortened in the study population after introducing the ERAS protocol, from a mean of 4.7 (SD=3.8) days to a mean of 3.8 (SD=3.2) days (P=.0001). The overall complication rate decreased from 24.3% to 16% (P=.02). Significant decreases in the rates of postoperative infections (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI]0.31-0.99) and cardiovascular complications (adjusted OR0.27, 95% CI0.09-0.79) were noted, without a significant increase in readmission rate (adjusted OR 0.50, 95% CI 0.21-1.07). Introducing an ERAS program for gynecologic oncology patients undergoing laparotomy was effective in shortening length of stay and the overall complication rate without a significant increase in readmission. Advocacy for broader implementation of ERAS among gynecologic oncology services and ongoing discussion on challenges and opportunities in the implementation process are warranted to improve patient outcomes and experiences.

The Effect of Older Age on the Perioperative Outcomes of Spinal Fusion Surgery in Patients With Lumbar Degenerative Disc Disease With Spondylolisthesis: A Propensity Score-Matched Analysis.

Degenerative spondylolisthesis (DS) is often treated with lumbar spinal fusion (LSF). However, there is concern that the morbidity of LSF may be prohibitively high in older adults. To evaluate the impact of advanced age on the safety of LSF for DS. Patients who underwent LSF for DS were retrospectively identified from National Surgical Quality Improvement Program datasets for 2011 to 2015 using Current Procedural Terminology codes. Data on demographic characteristics, comorbidities, surgical factors, and 30-d morbidity and mortality were collected. Propensity score matching (nearest neighbor) was performed with age (<70 vs ≥70 yr) as the dependent variable and sex, type of fusion procedure, number of levels fused, diabetes, smoking, hypertension, and chronic steroid use as covariates. Outcomes were compared between age <70 and ≥70 groups. The study cohort consisted of 2238 patients (n=1119, age <70; n=1119, age ≥70). The 2 age groups were balanced for key covariates including sex, race, diabetes, hypertension, CHF, smoking, chronic steroid use, type of fusion, and number of levels. Rates of all complications were similar between younger and older age groups, except urinary tract infection, which was more frequent among the ≥70 age group (OR 2.32, P=.009). Further, patients in the older age group were more likely to be discharged to a rehabilitation (OR 2.94, P<.001) or skilled care (OR 3.66, P<.001) facility, rather than directly home (OR 0.25, P<.001). LSF may be performed safely in older adults with DS. Our results suggest older age alone should not exclude a patient from undergoing lumbar fusion for DS.